This application has the long-term objective of reducing health care costs in the management of low back pain. Its specific aim is to analyze the utilization rates for various surgical procedures utilized in the management of back pain by means of small area analysis. The factors which influence the utilization rates for surgery will be identified by appropriate statistical analysis utilizing data tapes provided by various governmental and medical agencies. Regions and hospitals with similar utilization rates for surgery will be paired and a targeted medical education program aimed at the physicians in one of the paired areas will be designed and implemented. After an appropriate interval the small area analysis will be repeated to identify changes in utilization rates of surgery for low back pain so that the efficacy of Continuing Medical Education as a method of changing physician behavior can be evaluated. The ability to intervene selectively in one of each of the paired areas will permit us to establish appropriate controls to identify changes which may occur over time that are not related to our intervention. The potential of targeted continuing medical education to reduce health care costs will thereby be tested. In addition, four novel aspects of small area analysis will be evaluated: 1. Comprehensive analysis of new independent variables that may affect small area variation. 2. a new method for the inclusion of metropolitan areas in small area analysis. 3. Low back surgery in a small area analysis studied in detail. 4. A small area analysis will be carried out in a Western state. Preliminary data indicates that if we can effect a decrease in the utilization of back surgery which is equal to the recent annual increases in the United States over the past year, we could effect savings on a national level of approximately $400,000,000. This proposal establishes a model for such a program.